ENDOPHTHALMITIS

Endophthalmitis
The term refers to intraocular
inflammation predominantly
involving the vitreous cavity
and A/C, as a result of
intraocular colonization by
microrganisms.

Pathophysiology
In 29 43% of cataract surgery ,
intraocular contamination occurs
with facultative bacteria from ocular
surface without development of
endophthalmitis .
Immune privilege mechanisms are
particularly effective in the anterior
part of the eye.

pathophysiology
Ocular infection with infectious bacterial load
/with impairment of immune privilege of the eye
,leads to intense destructive inflammatory
reaction .
( Bact. Toxins ,proteases + intense host
inflammatory response ---------- injury to retina
,CB, A/S structures .
Intense inflammatory response ----- negative
microbiological studies .

Classification
1) Endogenous : bacterial / fungal / parasite.
2) Exogenous :
a) postoperative.
b) post traumatic .
c) Bleb associated .
d) miscellaneous ; e.g. microbial keratitis ,scleritis
(infectious)

Incidence
*Post cataract 0.07 0.5 %.
*post PKP 0.11%.
*post PPV 0.05 %.
*Bleb related 0.2 9.6 %.
*traumatic 2.4 8.0 % , up to 40% in rural areas with
IOFB.

Signs and symptoms

*Decrease VA.
*pain.
*A/C reaction +/- hypopyon.
*Vitritis .
*others: lid swelling , discharge ,
C.edema, chemosis.

D.Dx
*TASS.
*Complicated , prolong surgery .
*Preexisting uveitis .
*Retained lens material.
*Associated ocular injury .
NB : presence of significant vitritis =
infectious Endoph. Till proven
otherwise .

Microbial spectrum
Post cataract :CNS 33-77%
Staph. Aurus 10-21%
Streptococci 9-19%
G ve, fungi 6-22%
Delayed onset (chronic) post cataract:
Prop. Acne ,corynebacteria,fungi.
Post glaucoma Sx: CNS 67% early
Strept, H influ.

Cont.
Post traumatic : CNS 16 44 %
Bacillus 17 32%
G -ve 10 -18%
Strept. 8 21%
Fungi 4 14 %

Source of infection
*Mainly eye lids and conjunctiva.
*Other sources : e.g.
- lacrimal drainage syst.
Infections.
- Blephritis.
- infected socket in contralateral
prosthetic eye.

Risk factors for Endoph. Post

cataract surgery
*Disruption of the integrity of the barrier
between A/S and P/S ( post. Caps.tear,zonular
dialysis,vitreous loss).
*clear corneal incision > scleral tunnel.
*wound leakage in the first day post op.
*Silicon IOL > PMMA.

*no difference of incidence between

sutureless and suture technique if no leak.
*No diff. between inpatients and
outpatients.
*No diff. between

DM

and non DM.

*No diff. between disposable and reusable

instruments.

Prophylaxis
*Antiseptics: 5% povidone iodine for at least 3 minutes

prophylaxis

is the most important

in many
studies; decreasing conj +periorbit.skin flora .
*Single use instruments is always preferable esp. tubes.

*there has been no randomised controlled

studies of preoperative cutting of eye
lashes, available data in the literature
showed no association with the reduction
of the risk of Endoph.
*But taping back of the lashes with
adhesive tape is recommended.
* Treat any underlying predisposing cause
e.g. blephritis.

Antibiotics

Topical antibiotics esp. 4

generation
fluoroquinolones appears to be very effective in
reducing conj. Flora load , achieving high
concentrations in the in the A/C.
th

But no controlled clinical trial prove their effect in

reducing incidence of Endoph.

Abx

Systemic antibiotics preopertive or post

op has not proven to be of benefit against post op
Endoph.

In penetrating ocular trauma systemic +/- intravitreal

Abx shown to have some protective effects ; two
recent studies.

Abx

antibiotics to irrigation
solution , there was a debate about there use
Adding

but there is no study based evidence showing

reduction of Endoph.
Also , risk of endoth. Toxicity not studied .

Abx

Injection of intracameral
1mg/0.1ml of cefuroxime
(3000ug/ml @ a/c ) at the end of
surgery:
It has bee shown the risk of Endoph. with this regimen
reduced by almost 5 folds (ESCRS ) study
NB: cefuroxime resist. MRSA,MRSE,Ent.faecalis,pseud.aur.

Abx
Subconjunctival antibiotics:

It is very common practice to inject Abx

subconj. at conclusion of surgery.
*Gentamycin is not effective against
Strept. Species ,prop.acne.
*Subconj.cefuroxime --- 20ug/ml in A/C
much lower than intracameral.
*till now no proven evidence of its help.

Abx
*post op Abx use :

It is recommended to use post op Abx of

same type used preop esp. quinolones
for 1 - 2 weeks until the wound is
secured ; but this also not proven to be
effective but it is not harmful.
NB they recommendation to start them
in the first day very frequent (Q2hrs) for
one day then QID to decrease A/C
contamination load.

Diagnosis
*It is mainly clinical.
*Delay in diagnosis is not uncommon (steroids
,complications ,expected post op inflam.).
*B-scan is an aid , but some times it is misleading .
*if doubt, be safe and consider it as Endoph.,
no body is blaming of over protection but missing serious
irreversibly damaging pathology is this the situation.

Management of acute post op

Endophthalmitis
*It is a real ophthalmic emergency.

*controversies in management :
Vitreous tap + A/C sampling + intravitreal
Abx&steroids---- in cases VA >=HM (EVS)

VS
Primary Vitrectomy +intravitreal Abx&steroids in all
cases (ESCRS).

Mx
ESCRS recommend Primary Vitrectomy +intravitreal
Abx&steroids as a gold standard of care :

To:

dec. bact. Load , pus , remove most of the

inflammatory destructing cells and mediators ,
removing the scaffold (vitreous)

Mx
EVS recommends :

a) Vitreous tap + A/C sampling + intravitreal

Abx&steroids---- in cases VA >=HM.
b) Vitrectomy +intravitreal antibiotics &steroids
in cases VA < HM.
Why ?

-Comparative results founded ( organism

virulence).
-Avoiding delay vitreous tap + Abx .
-Avoiding vitr. Complications In a fragile retina .

* Inravitreal antibiotics
can be repeated every
48 hours according to
the response

Adjunctive measures
According to EVS systemic Abx do not appear
to have any effect on the course and the
outcome of endophthaalmitis.
they use ( amikacin + ceftazidime )
systemically ; and ( vancomycin
+ceftazidime ) intravitrealy.
They dont use same Abx , they dont take
in consideration of G +ve to be the most
common to be covered.
But :

So, at least in theory; IV Abx of

same type of intravitreal Abx can
contributes towards maintaining
effective Abx level within the eye .
Also , some practitioners will use
topical fortified same Abx for same
principle.

Cont. Adjunctive measures

*As mentioned earlier , the destructive agent in Endoph. Is
the intense inflammatory response + the bacterial toxins .
*Systemic (oral) steroids is recommended, studies does not
shown any negative effect on the infection course in cases
of bacterial endophthalmitis .
*also , topical steroids has same principle.

Chronic (delayed onset) post

operative endophhalmitis
It is very commonly misdiagnosed as
uveitis or post op. inflammation .
Problems:
a)High rate of recurrence.
b)Difficulty in culturing the organism(mostly prop. Acne)
because it is enclosed in the synechised capsular bag.

Dx &Mx

*If clinical diagnosis suspected :

1st step:
start systemic Clarithromycin 250mg po BD for 2/52
( it is concentrated 200 X more in macrophages,PMN
containing intracellular bacteria as prop.acne )
If improvement is successful keep close F/U

2nd step :
If no improvement in step one, consider PPV +
intravitreal Abx ( vancomycin +cefazoline ) + posterior
capsulotomy .

3rd step:
If no mprovements in step 2 remove IOL +surrounding
bag .

Outcomes of treatment
*in general more virulent organisms as : staph
aureus,strept, bacillus sp,pseud. Carry the worst visual
outcomes.
*low virulent organisms as ( CNS, P acne ) carry better
visual outcomes .

Out comes from EVS

@ 3/12 --- 41% had >=20/40.
69% had >=20/100.
@9 12/12 ---- 53% had >=20/40.
74% had >=20/100.
15% had < 5/200.
@ final follow up visit 5% had NLP.

Cont.

Chronic endoph. Carries a

favorable visual prognosis ,
one study showed final VA
>=20/40 in 80% of cases .

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